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HIV Independently Predicts Cardiovascular Disease in US Women
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CROI 2014, March 3-6, 2014, Boston
Mark Mascolini
HIV infection--independently of classic risk factors--nearly tripled the risk of cardiovascular disease in a study of more than 2000 women in the US Veterans Aging Cohort Study [1]. Higher heart disease risk with versus without HIV held true regardless of CD4 count. But women with a viral load below 500 copies did not have a higher cardiovascular disease risk than women without HIV, whereas women with a viral load above 500 copies did.
Several studies have found higher rates of cardiovascular disease in women with HIV than in the general population. But these studies often could not assess the impact of key risk factors such as smoking and HCV infection. To determine whether HIV by itself confers a higher risk of cardiovascular disease in women, Julie Womack (Yale University) and colleagues at other institutions analyzed cardiovascular disease incidence in women enrolled in the Veterans Aging Cohort Study Virtual Cohort, who have free access to HIV care.
All women were free of cardiovascular disease at their first clinical visit on April 1, 2003 or later. Observation continued until a first cardiovascular diagnosis (acute myocardial infarction, heart failure, or ischemic stroke), death, or December 31, 2009. Cox proportional hazards models to assess the impact of HIV on incident cardiovascular disease adjusted for age, race/ethnicity, lipids, smoking, blood pressure, diabetes, renal disease, obesity, hepatitis C, and substance use.
The study included 2190 women, 710 of them (32%) with HIV infection. In the groups with and without HIV, age (mean 43.2 and 44.0), race (61.6% and 59.4% African American), and Framingham cardiovascular risk score (mean 3.2 and 3.1) did not differ much. A higher proportion of women with HIV currently smoked (59.2% versus 40.5%), had HCV infection (24.4% versus 5.7%), abused alcohol (13.8% versus 5.0%), and abused cocaine (13.5% versus 3.6%). Almost half of HIV-negative women (44.6%) were obese, compared with one quarter of HIV-positive women (25.3%).
Among women with HIV, CD4 count averaged 468 and viral load 57,866 copies. Most women, 58.7%, were not taking antiretrovirals.
Through a median follow-up of 6 years, 86 women had a cardiovascular diagnosis, 46 of them (53%) with HIV infection. Cardiovascular disease-free survival over this time was significantly diminished in women with HIV compared with HIV-negative women (P < 0.001).
A Cox model adjusted for both demographic and Framingham cardiovascular risk factors determined that HIV infection independently tripled the risk of cardiovascular disease (adjusted hazard ratio [aHR] 2.8, 95% confidence interval [CI] 1.7 to 4.6). Other independent risk factors were hypertension (aHR 2.4, 95% CI 1.5 to 3.8), cocaine abuse or dependence (aHR 2.5, 95% CI 1.1 to 5.4), and older age. Factors not associated with cardiovascular risk in this analysis were race (black versus white), diabetes, lipids, smoking, statin use, hepatitis C, alcohol use or dependence, and body mass index.
Womack and colleagues then explored associations between HIV and cardiovascular disease according to CD4 count, viral load, and antiretroviral use. Compared with HIV-negative women, HIV-positive women in every CD4 stratum analyzed had an independently higher risk of cardiovascular disease:
-- 500 or more CD4s: aHR 2.3, 95% CI 1.3 to 4.4
-- 200 to 499 CD4s: aHR 2.9, 95% CI 1.5 to 5.7
-- Under 200 CD4s: aHR 3.8, 95% CI 1.9 to 7.6
Cardiovascular risk did not differ between women in these three CD4 strata.
Compared with HIV-negative women, positive women with a viral load at or above 500 copies had almost a quadrupled risk of cardiovascular disease (aHR 3.7, 95% CI 2.2 to 6.5). But HIV-positive women with a viral load below 500 copies did not have a higher cardiovascular disease risk than HIV-negative women, and risk did not differ between the two HIV groups.
Antiretroviral-treated women with a viral load at or above 500 copies had more than a quadrupled cardiovascular disease risk than women without HIV (aHR 4.4, 95% CI 2.0 to 10.0). But antiretroviral-treated women with a sub-500 viral load did not have a higher cardiovascular disease risk than HIV-negative women. HIV-positive women not taking antiretrovirals had a tripled risk of cardiovascular disease compared with HIV-negative women (aHR 3.0, 95% CI 1.8 to 5.1). Again, these three HIV groups did not differ from each other in cardiovascular disease risk.
The investigators believe their findings "have important policy and clinical implications given the growing number of HIV-positive women and the fact that heart disease is the leading cause of death among women in the US." They call for further research to explore etiology and predictors of heart disease in HIV-positive women.
Reference
1. Womack JA, Chang CCH, Armah KA, et al. HIV infection and the risk of cardiovascular disease in women. CROI 2014. Conference on Retroviruses and Opportunistic Infections. March 3-6, 2014. Boston. Abstract 734.
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